Area-level deprivation and preterm birth: Results from a national, commercially-insured population

Renee Mehra, Fatma M. Shebl, Shayna D. Cunningham, Urania Magriples, Eric Barrette, Carolina Herrera, Katy B Kozhimannil, Jeannette R. Ickovics

Research output: Contribution to journalArticlepeer-review

13 Scopus citations


Background: Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psychosocial factors. Methods: We conducted a retrospective cohort study using national, commercial health insurance claims data from 2011, obtained from the Health Care Cost Institute. Area-level deprivation was derived from principal components methods using ZIP code-level data. Multilevel structural equation modeling was used to examine mediating effects. Results: In total, 138,487 women with a live singleton birth residing in 14,577 ZIP codes throughout the United States were included. Overall, 5.7% of women had a preterm birth. In fully adjusted generalized estimation equation models, compared to women in the lowest quartile of area-level deprivation, odds of preterm birth increased by 9.6% among women in the second highest quartile (odds ratio (OR) 1.096; 95% confidence interval (CI) 1.021, 1.176), by 11.3% in the third highest quartile (OR 1.113; 95% CI 1.035, 1.195), and by 24.9% in the highest quartile (OR 1.249; 95% CI 1.165, 1.339). Hypertension and infection moderately mediated this association. Conclusions: Even among commercially-insured women, area-level deprivation was associated with increased risk of preterm birth. Similar to individual socioeconomic status, area-level deprivation does not have a threshold effect. Implementation of policies to reduce area-level deprivation, and the screening and treatment of maternal mediators may be associated with a lower risk of preterm birth.

Original languageEnglish (US)
Article number236
JournalBMC public health
Issue number1
StatePublished - Feb 27 2019

Bibliographical note

Funding Information:
This work was supported by the United States Health Resources & Services Administration (grant number R40MC28308); RM was supported by the National Institutes of Health (grant number 5T32HS017589–10) and the Herman Fellowship, Yale School of Public Health; CH was supported by the National Institutes of Health (grant number 2T32HS022242–06).

Publisher Copyright:
© 2019 The Author(s).


  • Area-level deprivation
  • Commercially-insured
  • Mediating pathways
  • Preterm birth


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